Methods for partial diversion of the intestinal tract

ABSTRACT

Devices and methods are used to modify a metabolic pathway of a digestive system by creating a pathway within the intestinal tract through an anastomosis between a proximal location within the intestinal tract and a distal location within the intestinal tract. In some examples, the small intestine has a first initial length and the created pathway defines a second length of the intestinal tract that is approximately ten to seventy percent of the first initial length of the small intestine.

PRIORITY

This application is a continuation-in-part of U.S. Non-Provisionalpatent application Ser. No. 15/161,512, filed May 23, 2016, published asU.S. Publication No. 2016/0262762, the disclosure of which isincorporated by reference herein; which is a divisional of U.S.Non-Provisional patent application Ser. No. 14/013,538, filed Aug. 29,2013, issued on Jun. 14, 2016 as U.S. Pat. No. 9,364,238, the disclosureof which is incorporated by reference herein; which claims priority toU.S. Provisional Patent Application No. 61/812,469, filed Apr. 16, 2013,the disclosure of which is incorporated by reference herein.

BACKGROUND

In some instances, it may be desirable to provide a side-to-sideanastomosis between two naturally occurring lumens within a patient'sbody. By way of example only, it may be desirable to provide ananastomosis between two portions of a patient's gastrointestinal tract,such as between the patient's duodenum and the patient's ileum. In somepatients, it may improve glucose control, serve as a treatment for type2 diabetes, and/or provide other results when the jejunum is diverted byan anastomosis. In such a procedure, a first enterotomy may be formed inthe sidewall of the duodenum while a second enterotomy is formed in thesidewall of the ileum. The sidewalls may then be placed adjacent to eachother to provide fluid communication through the first and secondenterotomies, enabling at least some chyme to pass through the first andsecond enterotomies to travel from the duodenum to the ileum withoutpassing through the jejunum.

One or more devices may be positioned within the first and secondenterotomies to hold the sidewalls of the duodenum and ileum together,thereby holding the first and second openings in alignment with eachother and maintaining patency through the openings. The device ordevices may compress the tissue, which may ultimately result in aserosa-to-serosa adhesion that secures the duodenum sidewall to theileum sidewall. In addition, tissue captured in the device or devicesmay eventually necrose, such that the device or devices is/areeventually released into the gastrointestinal tract and subsequentlypassed through the bowels. Traditional examples of anastomosis devicesinclude Denan's rings and the Murphy button. Examples of anastomosisprocedures and associated devices are taught in U.S. Provisional PatentApp. No. 61/697,845, entitled “Magnetic Compression Anastomosis Device,”filed Sep. 7, 2012, the disclosure of which is incorporated by referenceherein.

While a variety of anastomosis devices have been made and used, it isbelieved that no one prior to the inventor(s) has made or used aninvention as described herein.

BRIEF DESCRIPTION OF THE DRAWINGS

While the specification concludes with claims which particularly pointout and distinctly claim the invention, it is believed the presentinvention will be better understood from the following description ofcertain examples taken in conjunction with the accompanying drawings, inwhich like reference numerals identify the same elements and in which:

FIG. 1 depicts a diagrammatic view of a portion of a patient's digestivesystem, showing an anastomosis in the small intestines to divert chymefrom the patient's jejunum;

FIG. 2 depicts a partial perspective view of another exemplaryanastomosis to divert chyme from the patient's jejunum;

FIG. 3A depicts a perspective view of an exemplary anastomosiscompression device, in an expanded state;

FIG. 3B depicts a perspective view of the anastomosis compression deviceof FIG. 3A, in a partially compressed state;

FIG. 3C depicts a perspective view of the anastomosis compression deviceof FIG. 3A, in a compressed state;

FIG. 4 depicts a side elevational view of the distal end of an exemplaryinstrument operable to apply the anastomosis compression device of FIG.3A;

FIG. 5A depicts a perspective view of the instrument of FIG. 4 engagedwith the anastomosis compression device of FIG. 3A, with an arm of theinstrument in an extended position;

FIG. 5B depicts a perspective view of the instrument of FIG. 4 engagedwith the anastomosis compression device of FIG. 3A, with an arm of theinstrument in a retracted position;

FIG. 6A depicts a perspective view of a patient's digestive systemduring an anastomosis procedure, with an instrument approaching thepatient's duodenum to form an opening;

FIG. 6B depicts a perspective view of a patient's digestive systemduring the anastomosis procedure of FIG. 6A, with the opening formed inthe patient's duodenum;

FIG. 6C depicts a perspective view of a patient's digestive systemduring the anastomosis procedure of FIG. 6A, with an opening formed inthe patient's ileum;

FIG. 6D depicts a perspective view of a patient's digestive systemduring the anastomosis procedure of FIG. 6A, with the instrument of FIG.4 and the anastomosis compression device of FIG. 3A approaching theopening in the patient's duodenum;

FIG. 6E depicts a perspective view of a patient's digestive systemduring the anastomosis procedure of FIG. 6A, with the anastomosiscompression device of FIG. 3A being inserted in the opening in thepatient's duodenum;

FIG. 6F depicts a perspective view of a patient's digestive systemduring the anastomosis procedure of FIG. 6A, with the anastomosiscompression device of FIG. 3A fully inserted in the opening in thepatient's duodenum;

FIG. 6G depicts a perspective view of a patient's digestive systemduring the anastomosis procedure of FIG. 6A, with a retention feature ofthe anastomosis compression device of FIG. 3A being positioned outsidethe opening in the patient's duodenum;

FIG. 6H depicts a perspective view of a patient's digestive systemduring the anastomosis procedure of FIG. 6A, with the anastomosiscompression device of FIG. 3A being released to expand within thepatient's duodenum;

FIG. 6I depicts a perspective view of a patient's digestive systemduring the anastomosis procedure of FIG. 6A, with the anastomosiscompression device of FIG. 3A in the expanded configuration within thepatient's duodenum, and with a portion of tissue omitted to show theentirety of the anastomosis compression device;

FIG. 6J depicts a perspective view of a patient's digestive systemduring the anastomosis procedure of FIG. 6A, with the instrument of FIG.4 and the anastomosis compression device of FIG. 3A approaching theopening in the patient's ileum;

FIG. 6K depicts a perspective view of a patient's digestive systemduring the anastomosis procedure of FIG. 6A, with the anastomosiscompression device of FIG. 3A fully inserted in the opening in thepatient's ileum;

FIG. 6L depicts a perspective view of a patient's digestive systemduring the anastomosis procedure of FIG. 6A, with the anastomosiscompression device of FIG. 3A being released to expand within thepatient's ileum;

FIG. 6M depicts a perspective view of a patient's digestive systemduring the anastomosis procedure of FIG. 6A, with the anastomosiscompression device of FIG. 3A in the expanded configuration within thepatient's ileum;

FIG. 6N depicts a perspective view of a patient's digestive systemduring the anastomosis procedure of FIG. 6A, with the anastomosiscompression devices being urged toward each other to thereby urge theduodenum and the ileum toward each other;

FIG. 6O depicts a perspective view of a patient's digestive systemduring the anastomosis procedure of FIG. 6A, with the anastomosiscompression devices holding the openings in the duodenum and ileumtogether to form an anastomosis;

FIG. 6P depicts a perspective view of a patient's digestive systemduring the anastomosis procedure of FIG. 6A, with portions of tissueomitted to show the anastomosis compression devices in position to holdthe openings in the duodenum and ileum together to form an anastomosis;

FIG. 7A depicts a cross-sectional view of a pair of the anastomosiscompression devices of FIG. 3A opposingly positioned in a patient'sduodenum and ileum, with live tissue positioned between opposingsurfaces of the anastomosis compression devices;

FIG. 7B depicts a cross-sectional view of a pair of the anastomosiscompression devices of FIG. 3A opposingly positioned in a patient'sduodenum and ileum, with the tissue positioned between opposing surfacesof the anastomosis compression devices in a state of necrosis;

FIG. 7C depicts a cross-sectional view of a pair of the anastomosiscompression devices of FIG. 3A, with the anastomosis compression devicesbeginning to leave the anastomosis formed between the patient's duodenumand ileum;

FIG. 7D depicts a cross-sectional view of a pair of the anastomosiscompression devices of FIG. 3A, with the anastomosis compression devicespassing into the patient's ileum;

FIG. 7E depicts a cross-sectional view of a pair of the anastomosiscompression devices of FIG. 3A, with the anastomosis compression deviceshaving passed through the patient's ileum, leaving behind a secureanastomosis;

FIG. 8 depicts a perspective view of an exemplary alternativeanastomosis compression device, in a compressed state;

FIG. 9 depicts a perspective view of a resilient member of theanastomosis compression device of FIG. 8;

FIG. 10 depicts a top plan view of the resilient member of FIG. 9

FIG. 11 depicts a cross-sectional view of the anastomosis compressiondevice of FIG. 8, taken along line 11-11 of FIG. 8, with the resilientmember in a first position;

FIG. 12 depicts a cross-sectional view of the anastomosis compressiondevice of FIG. 8, taken along line 11-11 of FIG. 8, with the resilientmember in a second position;

FIG. 13 depicts a side elevational view of the distal end of anexemplary alternative instrument operable to apply the anastomosiscompression devices of FIG. 3A and FIG. 8;

FIG. 14 depicts a perspective view of an exemplary resilient feature ofthe instrument of FIG. 13;

FIG. 15 depicts a perspective view of another exemplary alternativeanastomosis compression device;

FIG. 16 depicts a top plan view of the anastomosis compression device ofFIG. 15;

FIG. 17 depicts an exploded perspective view of the anastomosiscompression device of FIG. 15;

FIG. 18 depicts a perspective view of the bottom side of a firstsubassembly of the anastomosis compression device of FIG. 15;

FIG. 19 depicts a perspective view of the top side of a secondsubassembly of the anastomosis compression device of FIG. 15;

FIG. 20A depicts a side elevational view of the first subassembly ofFIG. 18, with a retracting member in an extended position;

FIG. 20B depicts a side elevational view of the first subassembly ofFIG. 18, with the retracting member in a retracted position;

FIG. 21A depicts a side cross-sectional view of the anastomosiscompression device of FIG. 15, with the first subassembly positioned ina patient's duodenum and the second subassembly positioned in thepatient's ileum, and with the first subassembly separated from thesecond subassembly;

FIG. 21B depicts a side cross-sectional view of the anastomosiscompression device of FIG. 15, with the first subassembly coupled withthe second subassembly to secure the patient's duodenum and ileum inrelation to each other, and with the retracting member of the firstsubassembly in the extended position;

FIG. 21C depicts a side cross-sectional view of the anastomosiscompression device of FIG. 15, with the first subassembly coupled withthe second subassembly, and with the retracting member of the firstsubassembly in the retracted position to compress regions of thepatient's duodenum and ileum together at an anastomosis;

FIG. 22 depicts a perspective view of another exemplary alternativeanastomosis compression device;

FIG. 23 depicts an exploded perspective view of the anastomosiscompression device of FIG. 22;

FIG. 24 depicts a top plan view of a male member of the anastomosiscompression device of FIG. 22;

FIG. 25 depicts a top plan view of a female member of the anastomosiscompression device of FIG. 22;

FIG. 26 depicts a side cross-sectional view of the anastomosiscompression device of FIG. 22, with the male and female members securedtogether to compress regions of a patient's duodenum and ileum togetherat an anastomosis;

FIG. 27 depicts a perspective view of another exemplary alternativeanastomosis compression device;

FIG. 28 depicts a top plan view of the anastomosis compression device ofFIG. 27; and

FIG. 29 depicts a side cross-sectional view of the anastomosiscompression device of FIG. 27, taken along line 29-29 of FIG. 28.

The drawings are not intended to be limiting in any way, and it iscontemplated that various embodiments of the invention may be carriedout in a variety of other ways, including those not necessarily depictedin the drawings. The accompanying drawings incorporated in and forming apart of the specification illustrate several aspects of the presentinvention, and together with the description serve to explain theprinciples of the invention; it being understood, however, that thisinvention is not limited to the precise arrangements shown.

DETAILED DESCRIPTION

The following description of certain examples of the invention shouldnot be used to limit the scope of the present invention. Other examples,features, aspects, embodiments, and advantages of the invention willbecome apparent to those skilled in the art from the followingdescription, which is by way of illustration, one of the best modescontemplated for carrying out the invention. As will be realized, theinvention is capable of other different and obvious aspects, all withoutdeparting from the invention. Accordingly, the drawings and descriptionsshould be regarded as illustrative in nature and not restrictive.

I. Exemplary Intestinal Anastomosis

As noted above, it may be desirable to provide an anastomosis betweentwo naturally occurring lumens within a patient's body, such as withinthe patient's gastrointestinal tract. FIG. 1 shows an example of ananastomosis (2) formed between a proximal portion of a patient's jejunum(4) and the patient's ileum (6). The anastomosis (2) is located justdistal to the duodenojujenal flexure (8). The anastomosis (2) provides apath for fluid communication from the proximal portion of a patient'sjejunum (4) directly to the ileum (6), thereby providing a bypass of themajority of the jejunum (4). In particular, chyme that exits the stomach(10) may flow directly through the duodenum (12), then through just theproximal portion of the jejunum (4) and directly to the ileum (6) viathe anastomosis (2), without passing through the majority of the jejunum(4). In some instances, a portion of the chyme that exits the stomach(10) flows directly from the proximal portion of the jejunum (4) to theileum (6) via the anastomosis (2); while another portion passes theanastomosis (2) and flows through the remainder of the jejunum (4).Thus, anastomosis (2) may form a complete diversion of chyme or apartial diversion of chyme.

It should be understood that it may be necessary to create at least twoenterotomies in order to provide an anastomosis (2)—one opening for theupstream region of the lumen and another opening for the downstreamregion of the lumen. The tissue surrounding the two enterotomies may besecured together with the enterotomies in alignment in order to providethe anastomosis (2). Once these openings are aligned at the site of theanastomosis (2), a device may be used to compress and hold the tissuetogether to maintain alignment of the enterotomies forming theanastomosis (2). Holding the tissue together may promoteserosa-to-serosa adhesion, such that the serosa that is apposed at theanastomosis (2) eventually bonds together and thereby maintainsstructural integrity of the anastomosis (2) without the need forassistance by a surgically introduced device. In some instances, it maybe necessary to create one or more additional enterotomies in thegastrointestinal tract in order to surgically introduce a device thatcompresses the tissue together to maintain alignment of the openingsforming the anastomosis (2). These additional enterotomies may need tobe closed (e.g., using suture, etc.) after the anastomosis compressiondevice has been introduced to the site of the anastomosis (2). Thecreation and subsequent closure of these additional access enterotomiesmay impose additional time, cost, and/or risk in the surgical procedure.

The following disclosure includes examples of anastomosis compressiondevices that may be used to compress and hold the tissue together tomaintain alignment and patency of the openings forming the anastomosis(2). It should be understood that each of these devices may beintroduced into the lumens of the jejunum and ileum via the sameenterotomies that will eventually form the anastomosis (2). In otherwords, it is not necessary to create (and subsequently close) anyadditional enterotomies in order to position the below described devicesat the site of the anastomosis (2). It should also be understood thatthe devices described below are configured to maintain their positionsat the anastomosis (2) without requiring the devices to be sutured inplace. The devices include one device portion that is placed in one partof the gastrointestinal tract and another device portion that is placedin another part of the gastrointestinal tract. These device portions arebiased toward each other (e.g., by a resilient member, by magneticforces, etc.) and thereby compress tissue between opposing surfaces ofthe device portions. The compression provides a fluid-tight seal at theanastomosis (2), preventing chyme, etc. from leaking at the anastomosis(2). The edges of the opposing device surfaces that contact tissue arerounded or chamfered to prevent the device portions from cutting throughthe tissue of the gastrointestinal tract. The compressed tissueeventually necroses due to ischemia, such that the device portions andnecrosed tissue eventually leave the anastomosis (2) and pass throughthe gastrointestinal tract.

While FIG. 1 shows the anastomosis (2) positioned just distal to theduodenojujenal flexure (8) (e.g., approximately 100 cm distal to theduodenojujenal flexure (8)) and coupling the proximal portion of thejejunum (4) with the ileum (6), it should be understood that ananastomosis (2) may be positioned at various other suitable locationswithin the gastrointestinal tract. For instance, an anastomosis (2) maybe located proximal to the duodenojujenal flexure (8), thus directlycoupling the duodenum (12) with the ileum (6) such that chyme may bypassthe entire length of the jejunum (4) as shown in FIG. 2. In anotherexample, an anastomosis (2) may be located about 100 centimeters distalto the duodenojujenal flexure (8) and/or ligament of Treitz (19). Asanother merely illustrative example, an anastomosis (2) may provide adirect coupling between the stomach (10) and jejunum (4), such thatchyme may bypass the duodenum (12); or between the esophagus and stomach(10) to re-connect the tract after removing a portion of the esophagus;or between the colon and rectum after removing a portion of the colondue to a lesion, etc. In some examples, the anastomosis (2) may have aside-to-side orientation to connect adjacent portions of a lumen such asthe small intestine. Other suitable locations for an anastomosis (2)within the gastrointestinal tract will be apparent to those of ordinaryskill in the art in view of the teachings herein. It should also beunderstood that an anastomosis (2) may be located elsewhere in apatient's body; and that an anastomosis need not necessarily be locatedwithin the patient's gastrointestinal tract. It is contemplated that theexemplary anastomosis compression devices described below (andvariations thereof) may be used in various locations throughout apatient's body, not just the gastrointestinal tract.

By way of further example, and not limitation, in one example ametabolic pathway of the digestive system (3) is modified by creating apathway (5) within the intestinal tract (9) by establishing a connectionbetween a proximal location within the small intestine (11) and a distallocation within the intestinal tract (9). In the present example, theconnection is formed by way of an anastomosis (2). In some examples, theconnection is formed by way of a side-to-side anastomosis. Also in thepresent example, the proximal location within the small intestine (11)is distal to the duodenal papilla (17). In this manner, the pathway (5)serves as a shortcut added to the existing pathway defined by theintestinal tract (9) of the digestive system (3), such that the existingpathway of the intestinal tract (9) remains intact. Accordingly, theprocedures involved to create the pathway (5) do not transect, remove,or seal off any portion of the digestive system (3). Furthermore, theprocedure is thus fully reversible and the entire digestive system (3)can be fully returned to its original state.

In modifying the metabolic pathway of the digestive system (3) to createthe pathway (5), the small intestine (11) itself defines a first initiallength. The pathway (5) created defines a second length. This secondlength is represented as the bypassed region or bypass portion of theintestinal tract (9) that is created due to the anastomosis (2). In thismanner, the bypassed region is that length of the intestinal tract (9)that chyme passing through the intestinal tract (9) would not travelthrough when the chyme instead follows the shortcut pathway created bythe anastomosis (2). In this way, the second length can also be definedas the length commencing at the anastomosis (2) at the proximal locationin the intestinal tract (9) and terminating at the anastomosis (2) atthe distal location in the intestinal tract (9). In the present examplethe second length can be between about 10% and 70% of the first initiallength of the small intestine (11). In one instance of the presentexample, the second length is less than about 60% of the initial overalllength of the small intestine (11).

When performing the method to create the pathway (5) within theintestinal tract (9), natural orifice translumenal endoscopic surgery(also referred to as NOTES) may be used, where the procedure involvesone or more flexible endoscopes that are inserted into a patient via anatural orifice of the patient. Such natural orifices can include themouth or oral cavity for transgastric procedures, the anus fortranscolonic procedures, and/or the vagina for transvaginal procedures.Such natural orifices are not limited to only those mentioned above, butmay instead include any natural orifice of a patient. In some instancesa previous scar site may be used to insert the one or more flexibleendoscopes, such as through the navel or umbilicus. In view of theteachings herein, one skilled in the art will recognize that methods forenteroscopy such as double balloon enteroscopy or spiral enteroscopyusing a system like the Endo-Ease Discovery® SB made by Spirus Medical,LLC can facilitate the identification of both proximal and distallocations via flexible endoscopy. Furthermore, some procedures forcreating the pathway (5) may be performed completely endoscopically,completely laparoscopically, in a completely open procedure, or in a mixof any of these procedure types and/or in combination with naturalorifice procedure types. In view of the teachings herein, the varioustypes of procedures and levels of invasiveness that may be used with themethods of creating pathways within the intestinal tract (9) describedherein will be apparent to those of ordinary skill in the art.

In the present example, the proximal location, in addition to beingdistal to the duodenal papilla (17), can be in the duodenum (12),jejunum (4), or the ileum (6). The distal location can be in the jejunum(4), ileum (6), or colon (15). In one instance of the present example,the proximal location is in the duodenum (12), while the distal locationis in the jejunum (4). In another instance, the proximal location is inthe duodenum (12), while the distal location is in the ileum (6). Inanother instance, the proximal location is in the jejunum (4), while thedistal location is also in the jejunum (4). In another instance, theproximal location is in the jejunum (4), while the distal location is inthe ileum (6). In another instance, the proximal location is in thejejunum (4), while the distal location is in the colon (15). In anotherinstance, the proximal location is in the ileum (6), while the distallocation is also in the ileum. In another instance, the proximallocation is in the ileum (6), while the distal location is in the colon(15). In view of the teachings herein, other locations for the proximallocation and the distal location for the created pathway (5) will beapparent to those of ordinary skill in the art.

In the example where the proximal location for the connection is in thejejunum (4) and the distal location is in the colon (15), in oneinstance the proximal location is at least about 200 centimeters distalfrom the ligament of Treitz (19). In the example where the proximallocation for the connection is in the jejunum (4), in one instance, theproximal location is between about 10 centimeters and about 200centimeters distal to the ligament of Treitz (19), and in anotherinstance 100 centimeters distal to the ligament of Treitz (19). Asmentioned above, in procedures where the proximal location for theconnection is in the jejunum (4), one or more flexible endoscopes may beinserted into a patient via the oral cavity and/or the colon (15).

In the example where the distal location for the connection is in theileum (6), in one instance the distal location is between about 10centimeters and 300 centimeters proximal to the ileocecal junction (21),and in another instance 250 centimeters proximal to the ileocecaljunction (21). In the example where the distal location for theconnection is in the colon (15), it may be in either the ascendingportion of the colon, the transverse portion of the colon, or thedescending portion of the colon. In another example, the distal locationis about 250 centimeters proximal to the ileocecal junction (21), whilethe proximal location is about 100 centimeters from the ligament ofTreitz (19).

In an example where the connection is a side-to-side anastomosis (2), byway of example only and not limitation, the procedure includes formingthe anastomosis (2) by compression. In some such procedures, theprocedure involves introducing a first magnetically attractable device(100) to a first attachment region at the proximal location. Then theprocedure involves introducing a second magnetically attractable device(100) to a second attachment region at the distal location. Either oneor both of the first and second magnetically attractable devices (100)include at least one magnet (118). Also, the first magneticallyattractable device (100) includes a surface that mates with, or isconfigured to be oriented adjacent to, a corresponding surface on thesecond magnetically attractable device. The procedure further includescompressing a first lumen wall at the first attachment region and asecond lumen wall at the second attachment region between the first andsecond magnetically attractable devices (100). Further exemplaryfeatures and functionalities that may be incorporated into magneticallyattractable devices (100) will be described in greater detail below;while others will be apparent to those of ordinary skill in the art inview of the teachings herein. It should be understood, however, thatmagnetically attractable devices need not necessarily be used in allversions of the procedures described herein.

In another example where the connection is a side-to-side anastomosis(2), by way of example only and not limitation, the procedure includesforming the anastomosis (2) by mechanical fastening. In this regard theprocedure involves creating a first enterotomy (70) at the proximallocation, creating a second enterotomy (80) at the distal location, andmechanically fastening the first and second enterotomies (70, 80).

By way of further example, and not limitation, in one example thepathway (5) is created within the intestinal tract (9) by forming afirst opening (70) in a first hollow organ (11), and forming a secondopening (80) in a second hollow organ (11). It should be understood thatthe first hollow organ and the second hollow organ can be separateorgans or different portions of the same organ. By way of example andnot limitation, the first and second hollow organs may be differentportions of the small intestine. In other examples the first and secondhollow organs may be the small intestine and colon respectively. In viewof the teachings herein, other examples for the first and second holloworgans will be apparent to those of ordinary skill in the art.

With the first and second openings (70, 80) created, a first compressiondevice (100) is inserted into the first opening (70), and a resilientfeature (130) of the first compression device (100) is secured to aportion of tissue adjacent to the first opening (70). In this manner thesecured resilient feature (130) of the first compression device (100) ispositioned on the exterior of the first hollow organ (11). A secondcompression device (100) is inserted into the second opening (80), and aresilient feature (130) of the second compression device (100) issecured to a portion of tissue adjacent to the second opening (80). Inthis manner the secured resilient feature (130) of the secondcompression device (100) is positioned on the exterior of the secondhollow organ (11). To further create the pathway (5), the first andsecond hollow organs (11) are moved toward each other to align the firstand second compression devices (100) with each other. With the first andsecond compression devices (100) aligned, their positions are securedrelative to each other, and a layer of tissue from each of the firsthollow organ (11) and the second hollow organ (11) is compressed inapposition between the secured first and second compression devices(100).

In one instance of the proceeding example for creating the pathway (5)within the intestinal tract (9), the first opening (70) is formed withinthe small intestine (11) at a location distal to the duodenal papilla(17), and the second opening (80) is proximal to the ileocecal junction(21). In another instance, the first opening (70) is formed within thesmall intestine (11) at a location distal to the duodenal papilla (17),and the second opening (80) is distal to the ileocecal junction (21). Inyet another instance, the first opening (70) is formed within thejejunum (4) at a location about 100 centimeters (or about one-third thelength of the jejunum) distal to the ligament of Treitz (19), and thesecond opening (80) is formed within the jejunum (4) at a location about250 centimeters proximal to the ileocecal junction (21). In anotherinstance, the first opening (70) is formed in a proximal portion of thejejunum (4), and the second opening (80) is formed distal to the firstopening (70) at a distance between about 10% and about 70% of the lengthof the small intestine (11).

The above examples and procedures are merely exemplary and variousmodifications in the locations used or steps performed in creating oneor more pathways within the digestive system of a patient will beapparent to those or ordinary skill in the art in view of the teachingsherein.

The procedures described above and elsewhere herein may be performedusing any of the various devices described below. In addition, or in thealternative, the procedures described above and elsewhere herein may beperformed using any of the devices described in U.S. Pat. No. 8,828,031,entitled “Apparatus for Forming an Anastomosis,” issued Sep. 9, 2014,the disclosure of which is incorporated by reference herein; U.S. Pat.No. 8,828,032, entitled “Methods and Apparatus for Magnet-InducedCompression Anastomosis Between Adjacent Organs,” issued Sep. 9, 2014,the disclosure of which is incorporated by reference herein; U.S. Pat.No. 7,445,622, entitled “Anastomotic Ring Applier with Double MotionActuation,” issued Nov. 4, 2008, the disclosure of which is incorporatedby reference herein; U.S. Pat. No. 8,142,454, entitled “Apparatus andMethod for Magnetic Alteration of Anatomical Features,” issued Mar. 27,2012, the disclosure of which is incorporated by reference herein; U.S.Pat. No. 6,171,320, entitled “Surgical Clip,” issued Jan. 9, 2001, thedisclosure of which is incorporated by reference herein; U.S. Pat. No.8,870,899, entitled “Self-Assembling Magnetic Anastomosis Device Havingan Exoskeleton,” issued Oct. 28, 2014, the disclosure of which isincorporated by reference herein; U.S. Pat. No. 7,780,686, entitled“Anastomotic Device,” issued Aug. 24, 2010, the disclosure of which isincorporated by reference herein; U.S. Pat. No. 7,637,919, entitled“Anastomosis System for Performing Anastomosis in Body,” issued Dec. 29,2009, the disclosure of which is incorporated by reference herein; U.S.Pat. No. 8,197,498, entitled “Gastric Bypass Devices and Procedures,”issued Jun. 12, 2012, the disclosure of which is incorporated byreference herein; U.S. Pat. No. 9,381,041, entitled “Methods and Devicesfor Access Across Adjacent Tissue Layers,” issued Jul. 5, 2016, thedisclosure of which is incorporated by reference herein; U.S. Pat. No.8,864,781, entitled “Intestinal Bypass Using Magnets,” issued Oct. 21,2014, the disclosure of which is incorporated by reference herein; U.S.Pat. No. 8,684,995, entitled “Treatment Method,” issued Apr. 1, 2014,the disclosure of which is incorporated by reference herein; U.S. Pat.No. 9,456,820, entitled “Incisionless Gastric Bypass Method andDevices,” issued Oct. 4, 2016, the disclosure of which is incorporatedby reference herein; U.S. Pub. No. 2011/0137394, entitled “Methods andSystems for Penetrating Adjacent Tissue Layers,” published Jun. 9, 2011,the disclosure of which is incorporated by reference herein; U.S. Pub.No. 2007/0142850, entitled “Compression Anastomosis Device,” publishedJun. 21, 2007, the disclosure of which is incorporated by referenceherein; U.S. Pub. No. 2006/0036267, entitled “Methods and Apparatus forPerforming Malabsorptive Bypass Procedures within a Patient'sGastro-Intestinal Lumen,” published Feb. 16, 2006, the disclosure ofwhich is incorporated by reference herein; the journal article entitled“Endoscopic Intestinal Bypass Creation by Using Self-Assembling Magnetsin a Porcine Model,” by Dr. Marvin Ryou et al., from GastrointestinalEndoscopy, Vol. 83, No. 4, pp. 821-25, 2016; and/or the journal articleentitled “Minimally Invasive Entero-Enteral Dual-Path Bypass UsingSelf-Assembling Magnets,” by Dr. Marvin Ryou et al., from SurgicalEndoscopy, published online by Springer Feb. 19, 2016. Still otherdevices that may be used to perform the procedures described herein willbe apparent to those of ordinary skill in the art in view of theteachings herein.

II. Exemplary Folding Anastomosis Compression Device

A. Structural Features of Exemplary Folding Anastomosis CompressionDevice

FIGS. 3A-3C show an exemplary folding anastomosis compression device(100). Device (100) of the present example comprises a first end member(110), a second end member (120), a set of links (112, 114, 122, 124),and a resilient member (130). A first magnet (118) is disposed in firstend member (110) while a second magnet (128) is disposed in second endmember (120). Links (112, 114) are pivotally coupled with first endmember (110) by pins (140). Similarly, links (122, 124) are pivotallycoupled with second end member (120) by pins (140). Link (112) iscoupled with link (122) by a pin (140); while link (114) is coupled withlink (124) by a pin (140). It should be understood that the pivotalcouplings provided by pins (140) enable links (112, 114, 122, 124) topivot, thereby enabling device (100) to transition between an expandedconfiguration (FIG. 3A), to a partially compressed or collapsedconfiguration (FIG. 3B), and further to a fully compressed or collapsedconfiguration (FIG. 3C). When device (100) is in the expandedconfiguration, links (112, 114, 122, 124) define a diamond-shapedopening. In the present example, device (100) is configured such thatdevice (100) may fit through a conventional trocar (e.g., a 12 mmtrocar) when device (100) is in the compressed state. Various suitabledimensions and other structural configurations that may be used fordevice (100) will be apparent to those of ordinary skill in the art inview of the teachings herein.

Resilient member (130) of the present example comprises a wire formed ofresilient material. By way of example only, resilient member (130) maybe formed of nitinol and/or any other suitable material(s). Resilientmember (130) defines a first arm (132) having a first tip region (134),a second arm (136) having a second tip region (138), and a bend (139)separating first arm (132) from second arm (136). First tip region (134)and the remainder of first arm (132) together define an angle ofapproximately 90°, such that first tip region (134) extends transverselyfrom first arm (132). First tip region (134) is secured to link (112).Second tip region (138) and the remainder of second arm (136) togetherdefine an angle of approximately 90°, such that second tip region (138)extends transversely from second arm (136). Second tip region (138) issecured to link (114). Bend (139) is configured such that arms (132,136) together define an angle of approximately 45° when device (100) isin the expanded configuration. Of course, the various regions ofresilient member (130) may define any other suitable angles.

Resilient member (130) is configured to resiliently bias device (100) tothe expanded configuration. In particular, tip regions (134, 138) bearoutwardly on their associated links (112, 114). In some versions,resilient member (130) is resiliently biased to assume a straightconfiguration where arms (132, 136) would together define an angle ofapproximately 180°. Thus, resilient member (130) may remain stressedwhen device (100) is in the expanded configuration. In some otherversions, resilient member (130) is resiliently biased to assume aconfiguration where arms (132, 136) would together define an obtuseangle, an angle of approximately 90°, or an acute angle. It should beunderstood that, as links (112, 114) are resiliently biased outwardly bytip regions (134, 138) bearing directly on links (112, 114), links (112,114) will also drive links (122, 124) outwardly due to the coupling viapins (140). Resilient member (130) will thus indirectly drive links(122, 124) outwardly via links (112, 114). As will be described ingreater detail below, resilient member (130) may be engaged by anapplier instrument (200), which may hold device (100) in a compressedconfiguration while device (100) is being applied at an anastomosissite.

In some versions, one or more torsion springs are used to resilientlybias device (100) to the expanded configuration, in addition to or as analternative to resilient member (130) biasing device (100) to theexpanded configuration. By way of example only, a torsion spring may bepositioned in first end member (110) to resiliently bear outwardly onlinks (112, 114) (e.g., via arms that extend to the inner regions oflinks (112, 114), etc.). In addition or in the alternative, a torsionspring may be positioned in second end member (120) to resiliently bearoutwardly on links (122, 124) (e.g., via arms that extend to the innerregions of links (122, 124), etc.). Other suitable ways in which device(100) may be resiliently biased will be apparent to those of ordinaryskill in the art in view of the teachings herein.

Resilient member (130) of the present example is also configured to flexat the bend separating first tip region (134) from the remainder offirst arm (132); and at the bend separating second tip region (138) fromthe remainder of second arm (136). However, resilient member (130) isconfigured to bias arms (132, 136) such that bend (139) is biased towardfirst end member (110). In other words, resilient member (130) is biasedtoward a position where arms (132, 136) are oriented generally parallelwith links (112, 114, 122, 124) as shown in FIGS. 3A-3C. The flexibilityof resilient member (130) at the bend separating first tip region (134)from the remainder of first arm (132), and at the bend separating secondtip region (138) from the remainder of second arm (136), enables bend(139) and arms (132, 136) to be deflected away from links (112, 114).Such deflection may facilitate coupling of resilient member (130) withan applier instrument (200) as will be described in greater detailbelow. Such deflection may also facilitate coupling of resilient member(130) with tissue adjacent to an enterotomy as will also be described ingreater detail below.

It should be understood from the foregoing that resilient member (130)is configured to provide a resilient bias along at least two differentpaths. One such path is along a plane that is parallel to a planedefined by the upper surfaces of links (112, 114, 122, 124). This biasurges device (100) to the expanded configuration. Put another way, thepath of this bias is along the path traveled by links (112, 114, 122,124) during the transition between the compressed configuration and theexpanded configuration. The other path of resilient bias is along aplane that is perpendicular to the plane defined by the upper surfacesof links (112, 114, 122, 124). This bias urges resilient member (130) toa position where bend (139) and arms (132, 136) are oriented along aplane that is substantially parallel to a plane defined by the uppersurfaces of links (112, 114, 122, 124). Put another way, the path ofthis bias is perpendicular to the path traveled by links (112, 114, 122,124) during the transition between the compressed configuration and theexpanded configuration. In some other versions, more than one resilientmember (130) is used to provide the biases along these different paths.

While resilient member (130) is configured to facilitate coupling ofresilient member (130) with tissue adjacent to an enterotomy in thepresent example, various other kinds of features may facilitate suchcoupling in addition to or as an alternative to resilient member (130)facilitating such coupling. By way of example only, spikes, otherprojections, meshes, wire bristles, snap rings, suture purse strings,adhesives, and/or various other features may be provided to facilitatecoupling of resilient member (130) with tissue adjacent to anenterotomy.

While device (100) only has one resilient member (130) in the presentexample, it should be understood that device (100) may have more thanone resilient member (130). By way of example only, a second resilientmember (130) may be secured to links (122, 124). Such a second resilientmember (130) may be configured and positioned as a mirror image ofresilient member (130) described above, and may thus provide the samekind of operability as resilient member (130) described above. Stillother suitable configurations will be apparent to those of ordinaryskill in the art in view of the teachings herein.

B. Exemplary Applier Instrument for Folding Anastomosis CompressionDevice

FIGS. 4-5B show an exemplary instrument (200) that may be used to applydevice (100) to an anastomosis site. Instrument (200) of the presentexample comprises an outer sheath (210) and an inner member (220). Outersheath (210) has an angled distal end (212) that defines an opening(214). Inner member (220) is slidably disposed in outer sheath (210).Inner member (220) has a distal end (222) that is configured toselectively extend from or retract from opening (214) as inner member(220) is translated relative to sheath (210). Distal end (222) includesa proximally projecting hook member (224) that is configured to engagebend (139) of resilient member (130). The tip (226) of distal end (222)is rounded such that tip (226) is atraumatic in the present example.

As best seen in FIG. 5A, hook member (224) is configured to engage bend(139) of resilient member (130) when inner member (220) is advanced to adistal position where distal end (222) extends from opening (214). Wheninner member (220) is thereafter retracted relative to outer sheath(210), hook member (224) draws bend (139) and adjacent portions of arms(132, 136) into opening (214), such that bend (139) and adjacentportions of arms (132, 136) are disposed in the interior of sheath (210)as shown in FIG. 5B. The inner sidewalls of sheath (210) that defineopening (214) contact arms (132, 136) and prevent arms (132, 136) frompivoting outwardly. Sheath (210) and inner member (220) thus cooperateto hold device (100) in the compressed configuration while inner member(220) is in a retracted position. As will be described in greater detailbelow, this positioning may be maintained until device (100) is suitablypositioned within a bodily lumen (e.g., duodenum, jejunum, ileum, etc.),at which point inner member (220) may be advanced distally relative tosheath (210) to release device (100) at the anastomosis site.

In some exemplary uses, device (100) is first held in the compressedconfiguration by an operator's hand, by a grasping instrument, or insome other fashion. While device (100) is being so held in thecompressed configuration, hook member (224) is moved into position wherehook member (224) engages bend (139) as shown in FIG. 5A. Inner member(220) may then be retracted relative to sheath (210), before or afterthe operator releases their grip on device (100) with their hand,grasping instrument, etc., to the position shown in FIG. 5B. In someother exemplary uses, device (100) is in the expanded configuration whenhook member (224) is moved into position to engage bend (139). Once hookmember (224) is engaged with bend (139) while device (100) is in theexpanded configuration, inner member (220) is retracted relative toouter sheath (210) to the position shown in FIG. 5B. During thisretraction, the inner sidewalls of sheath (210) that define opening(214) contact arms (132, 136) and drive arms (132, 136) inwardly,thereby transitioning device (100) from the expanded configuration tothe compressed configuration. It should therefore be understood that theoperator may use instrument (200) to transition device (100) from theexpanded configuration to the compressed configuration and/or some othertechnique to transition device (100) from the expanded configuration tothe compressed configuration.

Various suitable features that may be used to provide selectiveadvancement and retraction of inner member (220) relative to outersheath (210) will be apparent to those of ordinary skill in the art inview of the teachings herein. It should also be understood that innermember (220) may be resiliently biased relative to outer sheath (210).For instance, inner member (220) may be resiliently biased to proximallyretract distal end (222) within outer sheath (210).

C. Exemplary Procedure for Creating an Anastomosis with FoldingAnastomosis Compression Device

FIGS. 6A-6P show an exemplary procedure in which device (100) andinstrument (200) are used in the creation of an anastomosis. Inparticular, FIG. 6A shows a conventional grasping instrument (50)holding a section of a patient's duodenum (12) while a cuttinginstrument (60) approaches the duodenum (12). By way of example only,grasping instrument (50) may comprise an ENDOPATH® endoscopic graspinginstrument by Ethicon Endo-Surgery, Inc. of Cincinnati, Ohio and/or anyother suitable kind of grasping instrument. By way of further exampleonly, cutting instrument (60) may comprise an ultrasonic surgicalinstrument such as the HARMONIC ACE® shears by Ethicon Endo-Surgery,Inc. of Cincinnati, Ohio and/or any other suitable kind of instrument.While grasping instrument (50) holds the duodenum (12), cuttinginstrument (60) is used to create an enterotomy (70) in the duodenum(12) as shown in FIG. 6B. Grasping instrument (50) is then used to holdthe patient's ileum (6) while cutting instrument (60) is used to createan enterotomy (80) in the ileum (6) as shown in FIG. 6C.

After enterotomies (70, 80) have been created, an instrument (200) witha preloaded compression device (100) is introduced as shown in FIG. 6D.While grasping device (50) holds the duodenum (12), instrument (200) isused to insert device (100) through enterotomy (70) as shown in FIG. 6E.As can be seen, second end member (120) of device (100) passes throughenterotomy (70) first. Instrument (200) continues to advance intoenterotomy (70) to position the entirety of device (100) in the lumen ofthe duodenum (12), as shown in FIG. 6F. It should be understood thatdevice (100) is in the compressed or collapsed configuration during theentire time that device (100) is inserted through enterotomy (70). Itshould also be understood that this compressed or collapsedconfiguration of device (100) may minimize stretching or tearing ofenterotomy (70) during passage of device (100) through enterotomy (70).

After device (100) has been fully inserted through enterotomy (70),instrument (200) is retracted from enterotomy (70). During thisretraction, hook member (224) remains engaged with bend (139) ofresilient member (130). In particular, and as shown in FIG. 6G,instrument (200) is angled during retraction such that first end member(110) of device catches on the interior surface of the duodenum (12),and such that resilient member (130) pivots away from links (112, 114)to enable bend (139) and adjacent portions of arms (132, 136) to passback out of enterotomy (70) while the rest of device (100) remains inthe duodenum (12). With hook member (224) still engaged with bend (139)of resilient member (130), inner member (220) is advanced distallyrelative to outer sheath (210), to a point where resilient member (130)is eventually positioned distal to opening (214) of sheath (210). Onceresilient member (130) clears sheath (210), the resilient bias ofresilient member (130) drives arms (132, 136) outwardly, therebytransitioning device (100) to the expanded state as shown in FIG. 6H.Instrument (200) is further manipulated and/or lifted away from thetissue surface to disengage resilient member (130) from hook member(224), and instrument (200) is then retracted as shown in FIG. 6I.

As can be seen in FIGS. 6H-6I, resilient member (130) captures tissuebetween resilient member (130) and the assembly formed by first endmember (110) and links (112, 114). The resilient bias of resilientmember (130) toward the assembly formed by first end member (110) andlinks (112, 114) provides a sustained grip on the tissue. This grip onthe tissue assists in maintaining the position of device (100) in theduodenum (12). As can also be seen in FIGS. 6H-6L the expansion ofdevice (100) in the duodenum (12) holds enterotomy (70) in an openstate, which thereby maintains patency through enterotomy (70) as willbe described in greater detail below. In the present example, thedistance between the exterior of the joint formed by links (112, 122)and the exterior of the joint formed by links (114, 124) isapproximately 2.6 cm; while the distance between the interior of thejoint formed by links (112, 122) and the interior of the joint formed bylinks (114, 124) is approximately 1.5 cm. Of course, any other suitabledimensions may be provided.

Once device (100) has been applied to the duodenum (12), another device(100) is applied to the ileum (6) in a similar fashion. In particular,instrument (200) is used to position another device (100) in relation toenterotomy (80), while grasping device (50) holds the ileum (6), asshown in FIG. 6J. This second device (100) is then inserted intoenterotomy (80) as shown in FIG. 6K. Instrument (200) is thenmanipulated to position resilient member (130) outside enterotomy (80)while the rest of device (100) remains within the ileum (6), and theinner member (220) of instrument (200) is advanced distally relative tosheath (210) to enable expansion of device (100) as shown in FIG. 6L.Device (100) is then released from instrument (200), leaving the seconddevice (100) deployed in the ileum (6) as shown in FIG. 6M.

As with device (100) in the duodenum (12), resilient member (130) ofdevice (100) in the ileum (6) captures tissue between resilient member(130) and the assembly formed by first end member (110) and links (112,114). The resilient bias of resilient member (130) toward the assemblyformed by first end member (110) and links (112, 114) provides asustained grip on the tissue. This grip on the tissue assists inmaintaining the position of device (100) in the ileum (6). As can alsobe seen in FIG. 6M, the expansion of device (100) in the ileum (6) holdsenterotomy (80) in an open state, which thereby maintains patencythrough enterotomy (80) as will be described in greater detail below.

After devices (100) are fully deployed in the duodenum (12) and theileum (6), devices (100) are urged toward each other as shown in FIG.6N. This urging continues until the duodenum (12) and the ileum (6) comein contact with each other at the regions associated with devices (100),as shown in FIG. 6O. As shown in FIG. 6P, with the duodenum (12) and theileum (6) so positioned, devices (100) are parallel with each other andare positioned such that enterotomies (70, 80) are aligned with eachother to form an anastomosis (2). This alignment of devices (100) andenterotomies (70, 80) is promoted by magnets (118, 128) of devices(100). Magnets (118) also secure the positioning of devices (100) inrelation to each other. In particular, magnet (118) of the first device(100) is attracted to magnet (118) of the second device (100); whilemagnet (128) of the first device (100) is attracted to magnet (128) ofthe second device (100). Magnets (118) thus remain in coaxial alignmentwith each other and magnets (128) remain in coaxial alignment with eachother. The magnetic fields of magnets (118, 128) and the forcesgenerated thereby are sufficient to hold devices (100) in place even asdigestion later occurs in the patient. In other words, devices (100)remain in place even during peristalsis in the duodenum (12) and in theileum (6). By way of example only, magnets (118, 128) may comprise partnumber D44-N52 from K&J Magnetics of Jamison, Pa. It should also beunderstood that the forces generated by the magnetic fields of magnets(118, 128) will substantially compress the tissue of the duodenum (12)and ileum (6) that is captured between the devices (100). The ultimateresults of such compression will be described in greater detail below.

As noted above, magnets (118, 128) provide alignment of devices (100)and also secure the positions of devices (100) within the duodenum (12)and the ileum (6). It should be understood that devices (100) mayinclude other features, in addition to or in lieu of magnets (118, 128),that promote alignment of devices (100) and secure the positions ofdevices (100) within the duodenum (12) and the ileum (6). For instance,devices (100) may include complementary nesting features such asprojections and pockets, alternating undulations, retractable constantforce springs, resilient clips, etc. Other suitable features that may beused to promote alignment of devices (100) and/or secure the positionsof devices (100) within the duodenum (12) and the ileum (6) will beapparent to those of ordinary skill in the art in view of the teachingsherein.

It should be understood that the procedure described above may beperformed in a minimally invasive fashion, with devices (100),instruments (50, 60, 200), and any other necessary instrumentation beinginserted through trocars or small incisions. It should also berecognized that the only enterotomies (70, 80) created in thegastrointestinal tract are joined together to form an anastomosis (2).Thus, there is no need to create any additional enterotomies in order toposition any devices or instrumentation; and no need to close any suchadditional enterotomies.

In the example described above and shown in the FIG. 6 series, devices(100) are oriented such that resilient members (130) are both orientedin the same direction, with both bends (139) pointing proximally. Insome other versions, devices (100) are applied at orientations such thatresilient members (130) are oriented in opposite directions. Forinstance, device (100) in the duodenum (12) may be oriented such thatbend (139) of resilient member (130) of device (100) applied in theduodenum (12) points proximally; while device (100) in the ileum (6) isoriented such that bend (139) of resilient member (130) of device (100)applied in the ileum (6) points distally.

FIGS. 7A-7E show the site of the anastomosis (2) after devices (100)have been fully deployed. In particular, FIG. 7A shows devices (100),the duodenum (12), and the ileum (6) at the stage shown in FIGS. 60-6P,just after deployment. As shown, tissue (13) of the duodenum (12) andtissue (7) of the ileum (6) is being compressed between devices (100).Over a period of time, the ischemia caused by this compression of tissue(7, 13) eventually results in necrosis of the tissue (7, 13), as shownin FIG. 7B. This necrosis eventually reaches a point where the tissue(7, 13) can no longer structurally support devices (100), such thatdevices (100) break free from the site of the anastomosis (2) as shownin FIG. 7C. Devices (100) remain held together due to the attractionbetween magnets (118, 128) and pass into the ileum (6) as shown in FIG.7D, eventually passing into the bowels and out from the patient withfeces. In some instances, some necrosed tissue (7, 13) may remaincaptured between devices (100). It should be understood that the size ofthe fluid passageway at the site of the anastomosis (2) may initially bethe size of the stretched enterotomies (70, 80) when devices (100) arefirst applied and secured relative to each other. However, the size ofthe fluid passageway at the site of the anastomosis (2) is eventuallythe size of the entire footprint of devices (100) once devices (100)break away from the site of the anastomosis (2).

When devices (100) have left the site of the anastomosis (2), thestructural integrity of the anastomosis (2) remains secure due tonatural tissue adhesions. In particular, the exterior of the duodenum(12) and the ileum (6) may have substantial serosa-to-serosa adhesion atthis point, due to the sustained contact between the duodenum (12) andthe ileum (6). In addition, the mucosa at the interior of the duodenum(12) and the ileum (6) may have remodeled itself to provide a smoothmucosal transition (90) between the duodenum (12) and the ileum (6) atthe site of the anastomosis (2), as shown in FIG. 7E. With theanastomosis (2) complete as shown in FIG. 7E, chyme may freely pass fromthe duodenum (12) to the ileum (6) via the anastomosis (2), withoutneeding to pass through the jejunum (4).

D. Exemplary Variations of Folding Anastomosis Compression Device andApplier Instrument

FIG. 8 shows an exemplary alternative folding anastomosis compressiondevice (300). Device (300) of this example may be used as an alternativeto device (100) as described above. Device (300) of this examplecomprises a first end member (310), a second end member (320), a set oflinks (312, 314, 322, 324), and a resilient member (330). A first magnet(318) is disposed in first end member (310) while a second magnet (328)is disposed in second end member (320). Links (312, 314) are pivotallycoupled with first end member (310) by pins (340). Similarly, links(322, 324) are pivotally coupled with second end member (320) by pins(340). Link (312) is coupled with link (322) by a pin (340); while link(314) is coupled with link (324) by a pin (340). It should be understoodthat the pivotal couplings provided by pins (340) enable links (312,314, 322, 324) to pivot, thereby enabling device (300) to transitionbetween an expanded configuration and a compressed or collapsedconfiguration, similar to device (100) described above. When device(300) is in the expanded configuration, links (312, 314, 322, 324)define a diamond-shaped opening. In the present example, device (300) isconfigured such that device (300) may fit through a conventional trocar(e.g., a 12 mm trocar) when device (300) is in the compressed state.Various suitable dimensions and other structural configurations that maybe used for device (300) will be apparent to those of ordinary skill inthe art in view of the teachings herein.

Resilient member (330) of the present example comprises a wire formed ofresilient material. By way of example only, resilient member (330) maybe formed of nitinol and/or any other suitable material(s). As best seenin FIGS. 9-10, resilient member (330) defines a first arm (332) having afirst tip region (334), a second arm (336) having a second tip region(338), and a coil bend (339) separating first arm (332) from second arm(336). First tip region (334) is joined to the remainder of first arm(332) by a coil bend (333), such that first tip region (334) isgenerally parallel with first arm (332). As best seen in FIGS. 11-12,link (312) defines a recess (350) that is configured to receive coilbend (333) and first tip region (334). Link (312) also defines a boss(352) that is configured to restrict movement of arm (352) and/or firsttip region (334). It should be understood that link (314) may includesimilar features. Second tip region (338) is joined to the remainder ofsecond arm (336) by a coil bend (337), such that second tip region (338)is generally parallel with second arm (336). Coil bend (339) isconfigured such that arms (332, 336) together define an angle ofapproximately 45° when device (300) is in the expanded configuration. Ofcourse, the various regions of resilient member (330) may define anyother suitable angles.

Resilient member (330) is configured to resiliently bias device (300) tothe expanded configuration. In particular, coil bends (333, 337) and tipregions (334, 338) bear outwardly on their associated links (312, 314).In some versions, resilient member (330) is resiliently biased to assumea straight configuration where arms (332, 336) would together define anangle of approximately 180°. Thus, resilient member (330) may remainstressed when device (300) is in the expanded configuration. In someother versions, resilient member (330) is resiliently biased to assume aconfiguration where arms (332, 336) would together define an obtuseangle, an angle of approximately 90°, or an acute angle. It should beunderstood that, as links (312, 314) are resiliently biased outwardly bycoil bends (333, 337) and tip regions (334, 338) bearing directly onlinks (312, 314), links (312, 314) will also drive links (322, 324)outwardly due to the coupling via pins (340). Resilient member (330)will thus indirectly drive links (322, 324) outwardly via links (312,314). As with resilient member (130) described above, resilient member(330) of the present example may be engaged by an applier instrument(200), which may hold device (300) in a compressed configuration whiledevice (300) is being applied at an anastomosis site.

Resilient member (330) of the present example is also configured to flexat coil bends (333, 337). However, resilient member (330) is configuredto bias arms (332, 336) such that coil bend (339) is biased toward firstend member (310). In other words, resilient member (330) is biasedtoward a position where arms (332, 336) are oriented generally parallelwith links (312, 314, 322, 324) as shown in FIGS. 8 and 11. Theflexibility of resilient member (330) at coil bends (333, 337) enablescoil bend (339) and arms (332, 336) to be deflected away from links(312, 314) as shown in FIG. 12. Such deflection may facilitate couplingof resilient member (330) with instrument (200). Such deflection mayalso facilitate coupling of resilient member (330) with tissue adjacentto an enterotomy as described above.

It should be understood from the foregoing that resilient member (330)is configured to provide a resilient bias along at least two differentpaths. One such path is along a plane that is parallel to a planedefined by the upper surfaces of links (312, 314, 322, 324). This biasurges device (300) to the expanded configuration. Put another way, thepath of this bias is along the path traveled by links (312, 314, 322,324) during the transition between the compressed configuration and theexpanded configuration. The other path of resilient bias is along aplane that is perpendicular to the plane defined by the upper surfacesof links (312, 314, 322, 324). This bias urges resilient member (330) toa position where bend (339) and arms (332, 336) are oriented along aplane that is substantially parallel to a plane defined by the uppersurfaces of links (312, 314, 322, 324). Put another way, the path ofthis bias is perpendicular to the path traveled by links (312, 314, 322,324) during the transition between the compressed configuration and theexpanded configuration. In some other versions, more than one resilientmember (330) is used to provide the biases along these different paths.It should also be understood that another resilient member (330) may besecured to links (322, 324).

As yet another merely illustrative variation, one or more components ofdevices (100, 300) may be configured to biodegrade to facilitate passageof device (100, 300) through the gastrointestinal tract after theanastomosis (2) has been sufficiently formed. In some such versions, thebiodegradability promotes collapse of device (100, 300) to aconfiguration similar to the compressed configuration described above(e.g., as shown in FIGS. 3C and 8). By way of example only, resilientmember (130, 330) may be configured to biodegrade or at least lose itsresilience, such that device (100, 300) may freely collapse. As anotherexample, device (100, 300) may include a non-biodegradable secondresilient member (not shown) that is configured to bias device (100,300) to a collapsed state. Such a second resilient member may have alower spring constant than resilient member (130, 330), such thatresilient member (130, 330) provides a stronger bias toward the expandedstate while resilient member (130, 330) remains intact. Once resilientmember (130, 330) biodegrades, its bias is eventually overcome by thebias of the second resilient member, which urges device (100, 300) tothe collapsed state. Of course, the second resilient member need notnecessarily be non-biodegradable (e.g., the second resilient member maysimply take longer to degrade than resilient member (130, 330), etc.).Still other suitable ways in which biodegradability may be incorporatedinto devices (100, 300) will be apparent to those of ordinary skill inthe art in view of the teachings herein.

FIG. 13 shows an exemplary instrument (400) that may be used to applydevice (100, 300) to an anastomosis site. Instrument (400) of thisexample may be used as an alternative to device (200) as describedabove. Instrument (400) of this example comprises an outer sheath (410),an inner member (420), and a tip member (440). Outer sheath (410) has anangled distal end (412) that defines an opening (not shown) similar toopening (214) described above. Inner member (420) is slidably disposedin outer sheath (410). Inner member (420) has a distal end (422) that isconfigured to selectively extend from or retract from the opening ofouter sheath (410) as inner member (420) is translated relative tosheath (410). Distal end (422) includes a proximally projecting hookmember (424) that is configured to engage bend (139) or coil bend (330)of resilient member (130, 330). The tip (426) of distal end (422) isrounded such that tip (426) is atraumatic in the present example.

As described above with respect to hook member (224), hook member (424)is configured to engage bend (139) or coil bend (339) of resilientmember (130, 330) when inner member (420) is advanced to a distalposition where distal end (422) extends from the opening of outer sheath(410). When inner member (420) is thereafter retracted relative to outersheath (410), hook member (424) draws bend (139) or coil bend (339) andadjacent portions of arms (132, 136, 332, 336) into the opening ofsheath (410), such that bend (139) or coil bend (339) and adjacentportions of arms (132, 136, 332, 336) are disposed in the interior ofsheath (410). The inner sidewalls of sheath (410) that define theopening contact arms (132, 136, 332, 336) and prevent arms (132, 136,332, 336) from pivoting outwardly. Sheath (410) and inner member (420)thus cooperate to hold device (100, 300) in the compressed configurationwhile inner member (420) is in a retracted position. As described above,this positioning may be maintained until device (100, 300) is suitablypositioned within a bodily lumen (e.g., duodenum, jejunum, ileum, etc.),at which point inner member (420) may be advanced distally relative tosheath (410) to release device (100, 300) at the anastomosis site.

As shown in FIGS. 13-14, tip member (440) of the present exampleincludes an angled tip portion (442) and an associated bend (444). Tipportion (442) terminates in an arcuate edge (446). Bend (444) is angledsuch that tip portion (442) projects proximally. In some versions, bend(444) defines an acute angle. In some other versions, bend (444) definesan angle of approximately 45°. Alternatively, any other suitable anglemay be used. Tip member (440) of this example is configured to createand/or stretch an enterotomy to facilitate deployment of device (100,300) in the gastrointestinal tract. In the present example, tip member(440) is coupled with an energy source (450). In some versions, energysource (450) comprises a piezoelectric element that is operable to causetip member (440) to vibrate at ultrasonic frequencies, such that tipmember (440) may be selectively activated like an ultrasonic scalpelblade. In some other versions, energy source (450) is operable toactivate tip member (440) with monopolar RF energy. With a ground padengaging the skin of the patient, tip member (440) may thus act as anelectrosurgical scalpel blade. Regardless of how tip member (440) isenergized, it should be understood that device (100, 300) and otherportions of instrument (400) may be isolated from the energization. Ofcourse, energy source (450) is merely optional, and tip member (440) mayinstead present a passive sharp edge or even be atraumatic (e.g., inversions where tip member (440) is only used to stretch an enterotomy,etc.). By way of example only, the distal face of tip portion (442) maybe convex. Bend (444) may also present a convex edge.

In some versions, bend (444) provides a living hinge that enables tipportion (442) to transition from a bent position as shown in FIGS. 13-14to a substantially straight position where tip portion (442) issubstantially aligned with the remainder of tip member (440). In somesuch versions, tip portion (442) is resiliently biased to assume thebent position shown in FIGS. 13-14. As tip portion (442) is retractedproximally relative to outer sheath (410) and relative to inner member(420), the proximal face of tip portion (442) cams against the distalface of device (100, 300) that is being held by instrument (400), suchthat tip portion (442) deflects distally and pivots about bend (444).Tip member (440) may continue to retract proximally until tip portion(442) is fully disposed in outer sheath (410). In the present example,the retraction of tip member (440) would not begin until after device(100, 300) has been positioned within the gastrointestinal tract. Aftertip portion (442) is fully disposed in outer sheath (410), device (100,300) would then be released from instrument in the gastrointestinaltract. Other suitable ways in which instrument (400) may be operatedwill be apparent to those of ordinary skill in the art in view of theteachings herein.

Various suitable features that may be used to provide selectiveadvancement and retraction of inner member (420) and tip member (440)relative to outer sheath (410) will also be apparent to those ofordinary skill in the art in view of the teachings herein. It shouldalso be understood that inner member (420) may be resiliently biasedrelative to outer sheath (410). For instance, inner member (420) may beresiliently biased to proximally retract distal end (422) within outersheath (410). Still other suitable features and configurations forinstruments that may be used to apply devices (100, 300) will beapparent to those of ordinary skill in the art in view of the teachingsherein.

III. Exemplary Anastomosis Compression Device with Axially Biased Member

FIGS. 15-21C show another exemplary anastomosis compression device (500)that may be used to secure an anastomosis between two hollow organs(e.g., between the duodenum and the ileum, etc.). Device (500) of thisexample comprises a female portion (510) and a male portion (560).Portions (510, 560) are configured to selectively couple together at ananastomosis site and compress tissue adjacent to an anastomosis opening,similar to devices (100, 300) described above. As will be described ingreater detail below, female portion (510) is configured to resilientlybias male portion (560) toward female portion (510) to maintaincompression of tissue while device (500) is installed at the anastomosissite. Device (500) defines an opening (580) providing a path for fluidcommunication at the anastomosis site while device (500) resides at theanastomosis site.

As shown in FIGS. 15-18, female portion (510) comprises an assemblyformed by a base member (512), a retaining ring (520), a coupler (530),and a wave spring assembly (540). As best seen in FIGS. 21A-21C, basemember (512) defines an internal annular shoulder (516). Wave springassembly (540) is captured between annular shoulder (516) of base member(512) and an annular flange (532) of coupler (530). Wave spring assembly(540) is resiliently biased to urge annular flange (532) away fromannular shoulder (516), along an axis shared by flange (532) andshoulder (516). Retaining ring (520) is configured to selectively couplewith base member (512) and thereby secure coupler (530) within basemember (512).

Coupler (530) further comprises a first set of arms (534) and a secondset of arms (536). As best seen in FIGS. 20A-20B, each arm (534)includes an inwardly directed snap-fit barb (535). As best seen in FIG.18, each arm (536) includes an opening (537). As best seen in FIGS. 17and 20A-20B, openings (537) are configured to removably receive acylindraceous retaining member (550). Retaining member (550) isconfigured to engage the bottom surface (514) of base member (512) andhold coupler (530) in an extended position as shown in FIG. 20A. In theextended position, barbs (535) are substantially spaced away from bottomsurface (514), and wave spring assembly (540) is in a substantiallystressed, compressed configuration. This configuration is also shown inFIGS. 21A-21B. When retaining member (550) is withdrawn from openings(537), the resilient bias of wave spring assembly (540) drives coupler(530) upwardly into a retracted configuration as shown in FIGS. 20B and21C. In this configuration, barbs (535) are substantially closer tobottom surface (514).

As best shown in FIGS. 17 and 19, male portion (560) comprises a base(562) having an upwardly extending elliptical flange (564) and anupwardly extending post feature (566). Post feature (566) includes apair of vertically extending slots (567), a pair of retainer openings(568), and a pair of snap-fit barb openings (569). Slots (567) areconfigured to accommodate retaining member (550) when male portion (560)is initially coupled with female portion (510) as will be described ingreater detail below. Retainer openings (568) are configured to receivecylindraceous retaining members (570), which may be used to position andhold male portion (560). Openings (569) are configured to receive barbs(535) of coupler (530) in a snap-fit fashion, as will also be describedin greater detail below.

In an exemplary use of device (500) is shown in FIGS. 21A-21C, in whichretaining members (550, 570) have been omitted for clarity. In theexemplary use, an enterotomy (70) is created in the duodenum (12) and anenterotomy (80) is created in the ileum (6), as described above withrespect to an exemplary use of device (100). Female portion (510) isthen inserted through the enterotomy (70) and oriented such that arms(534, 536) protrude outwardly through the enterotomy (70), as shown inFIG. 21A. Female portion (510) is held in position in the duodenum (12)by retaining member (550). Male portion (560) is inserted through theenterotomy (80) and is oriented such that post feature (566) protrudesoutwardly through the enterotomy (80). Male portion (560) is held inposition in the ileum (6) by retaining members (570).

With portions (510, 560) positioned as shown in FIG. 21A, portions (510,560) are then brought toward each other, drawing the duodenum (12) andthe ileum (6) closer together. Retaining members (570) are removed fromopenings (568), providing clearance for post feature (566) to enter theinterior of coupler (530) to the point where barbs (535) snap intoopenings (569) as shown in FIG. 21B. At this stage retaining member(550) remains disposed in openings (537). Retaining member (550) isfurther accommodated within slots (567) of post feature (566).

After reaching the stage shown in FIG. 21B, retaining member (550) isremoved from openings (537). This enables wave spring assembly (540) todrive coupler (530) to the retracted position relative to base member(512). With barbs (535) disposed in openings (569) of male member (560),this movement of coupler (530) drives male member (560) toward basemember (512). This movement of male ember (560) toward base member (512)compresses the layers of tissue (7, 13) between flange (564) and thebottom surface (514) of base member (512), as shown in FIG. 21C. Thiscompression of tissue (7, 13) provides a secure seal of the anastomosisformed by the fully assembled device (500). Over a period of time, theischemia caused by this compression of tissue (7, 13) also eventuallyresults in necrosis of the tissue (7, 13), as described above. Device(500) thus eventually breaks free from the anastomosis site and passesthrough the patient's gastrointestinal tract as described above in thecontext of device (100).

It should be understood that after device (500) has left the site of theanastomosis (2), the structural integrity of the anastomosis (2) remainssecure due to natural tissue adhesions. In particular, the exterior ofthe duodenum (12) and the ileum (6) may have substantialserosa-to-serosa adhesion at this point, due to the sustained contactbetween the duodenum (12) and the ileum (6). In addition, the mucosa atthe interior of the duodenum (12) and the ileum (6) may have remodeleditself to provide a smooth mucosal transition (90) between the duodenum(12) and the ileum (6) at the site of the anastomosis (2). While femaleportion (510) is applied in the duodenum (12) and male portion (560) isapplied in the ileum (6) in the above example, it should be understoodthat female portion (510) may instead be applied in the ileum (6) whilemale portion (560) is applied in the duodenum (12). Furthermore, device(500) may be applied in other regions of the gastrointestinal tract orin some other portion of the human anatomy. Various other suitable waysin which device (500) may be configured and used will be apparent tothose of ordinary skill in the art in view of the teachings herein.

IV. Exemplary Anastomosis Compression Device with Corkscrew InsertionFeatures

FIGS. 22-26 show another exemplary anastomosis compression device (600)that may be used to secure an anastomosis between two hollow organs(e.g., between the duodenum and the ileum, etc.). Device (600) of thisexample comprises a male portion (610) and a female portion (660).Portions (610, 660) are configured to selectively couple together at ananastomosis site and compress tissue adjacent to an anastomosis opening,similar to devices (100, 300) described above. Male portion (610)comprises a post feature (620) and a corkscrew feature (630). As bestseen in FIG. 24, post feature (620) defines a passageway (622) having aninternal flat (624). As best seen in FIG. 23, a similar flat (626) isformed in the exterior of post feature (620). Corkscrew feature (630)terminates in an atraumatic free end (632).

Female portion (660) comprises a post feature (680) and a corkscrewfeature (690). As best seen in FIG. 25, post feature (680) defines apassageway (682) having an internal flat (684). Corkscrew feature (690)terminates in an atraumatic free end (692). Passageway (682) of femaleportion (660) is configured to receive post feature (620) of maleportion (610). Flat (684) is configured to complement flat (626) toenable insertion of post feature (620) in passageway (682) and to ensureappropriate angular alignment of male portion (610) relative to femaleportion (660). Corkscrew features (630, 690) are configured such thatwhen portions (610, 660) are fully coupled together, corkscrew features(630, 690) will deform slightly, compressing any tissue captured betweenopposing faces of corkscrew features (630, 690). Corkscrew features(630, 690) may thus be formed of a resilient material (e.g., a resilientplastic, etc.).

In an exemplary use of device (600), an enterotomy (70) is created inthe duodenum (12) and an enterotomy (80) is created in the ileum (6), asdescribed above with respect to an exemplary use of device (100). Maleportion (610) is inserted through the enterotomy (70) in the duodenum(12) and is oriented such that post feature (620) protrudes outwardlythrough the enterotomy (70). During this insertion, male portion (610)may be titled such and rotated such that corkscrew feature (630) passesthrough the enterotomy (70) progressively, without requiring theenterotomy (70) to be widened further beyond the outer diameter definedby post feature (620). Female portion (660) is inserted through theenterotomy (80) in the ileum (6) and is oriented such that post feature(680) protrudes outwardly through the enterotomy (80). During thisinsertion, female portion (660) may be titled such and rotated such thatcorkscrew feature (690) passes through the enterotomy (80)progressively, without requiring the enterotomy (80) to be widenedfurther beyond the outer diameter defined by post feature (680).

With male portion (610) disposed in the duodenum (12) and female portion(660) disposed in the ileum (6) as described above, portions (610, 660)are then brought toward each other, drawing the duodenum (12) and theileum (6) closer together. Male portion (610) is then inserted inpassageway (682) of female portion (660), such that portions (610, 660)are coupled together as shown in FIG. 26. At this stage, corkscrewfeature (630) bears on the tissue (7) of the duodenum (12) whilecorkscrew feature (690) bears on the tissue (13) of the ileum (6) in theopposite direction, such that the layers of tissue (7, 13) arecompressed between corkscrew features (630, 690). This compression oftissue (7, 13) provides a secure seal of the anastomosis formed by thefully assembled device (600). Over a period of time, the ischemia causedby this compression of tissue (7, 13) also eventually results innecrosis of the tissue (7, 13), as described above. Device (600) thuseventually breaks free from the anastomosis site and passes through thepatient's gastrointestinal tract as described above in the context ofdevice (100).

Corkscrew features (630, 690) may be configured such that tissue (7, 13)is compressed along any suitable portion of the length of corkscrewfeatures (630, 690) when portions (610, 660) are fully coupled together.As can also be seen in FIG. 26, the tissue contacting regions ofcorkscrew features (630, 690) include rounded corners (634, 694), whichmay prevent corkscrew features (630, 690) from prematurely migratingthrough the tissue (7, 13).

In some versions, male portion post feature (620) fits snugly inpassageway (682), such that portions (610, 660) remain secured togetherthrough an interference fitting. In some other versions, portions (610,660) comprise complementary snap-fit features that secure portions (610,660) together. In still other versions, portions (610, 660) comprisemagnetic features that secure portions (610, 660) together. Still othersuitable ways in which portions (610, 660) may be secured together willbe apparent to those of ordinary skill in the art in view of theteachings herein.

It should be understood that after device (600) has left the site of theanastomosis (2) (e.g., after tissue (7, 13) within the footprint ofdevice (600) has necrosed), the structural integrity of the anastomosis(2) remains secure due to natural tissue adhesions. In particular, theexterior of the duodenum (12) and the ileum (6) may have substantialserosa-to-serosa adhesion at this point, due to the sustained contactbetween the duodenum (12) and the ileum (6). In addition, the mucosa atthe interior of the duodenum (12) and the ileum (6) may have remodeleditself to provide a smooth mucosal transition (90) between the duodenum(12) and the ileum (6) at the site of the anastomosis (2). While maleportion (610) is applied in the duodenum (12) and female portion (660)is applied in the ileum (6) in the above example, it should beunderstood that male portion (610) may instead be applied in the ileum(6) while female portion (660) is applied in the duodenum (12).Furthermore, device (600) may be applied in other regions of thegastrointestinal tract or in some other portion of the human anatomy.Various other suitable ways in which device (600) may be configured andused will be apparent to those of ordinary skill in the art in view ofthe teachings herein.

V. Exemplary Anastomosis Compression Device with Biased Pivoting Links

FIGS. 27-29 show another exemplary anastomosis compression device (700)that may be used to secure an anastomosis between two hollow organs(e.g., between the duodenum and the ileum, etc.). Device (700) of thisexample comprises a first plate (710), a second plate (720), and a pairof links (730). Plates (710, 720) define respective rectangular openings(712, 722). Links (730) are positioned at the lateral sides of openings(712, 722). One end of each link (730) is pivotally secured to plate(710) at one end of opening (712) by a pin (740); while the other end ofeach link (730) is pivotally secured to plate (720) at the opposite endof opening (722) by a pin (740). Spacers (750) are positioned coaxiallyalong each pin (740), to maintain the ends of links (730) inspaced-apart positions.

In the present example, plates (710, 720) are biased toward each other,yet plates (710, 720) may be separated by pivoting links (730) at pins(740) as shown in FIG. 27. In some versions, torsion springs (e.g.,positioned about pins (740)) are used to resiliently bias plates (710,720). In some other versions, magnets are used to magnetically biasplates (710, 720). Other suitable ways in which plates (710, 720) may bebiased toward each other will be apparent to those of ordinary skill inthe art in view of the teachings herein. It should also be understoodthat device (700) may include a pull-pin, sliding lock feature, and/orother type of feature that selectively assists in keeping plates (710,720) separate from each other without the operator having to manuallyresist the bias of plates (710, 720) during positioning of device (700).Various suitable forms that such a bias resistance feature may take willbe apparent to those of ordinary skill in the art in view of theteachings herein.

In an exemplary use of device (700), an enterotomy (70) is created inthe duodenum (12) and an enterotomy (80) is created in the ileum (6), asdescribed above with respect to an exemplary use of device (100). Plate(710) is inserted through the enterotomy (70) in the duodenum (12) andis oriented such that links (730) protrude outwardly through theenterotomy (70). Plate (720) is inserted through the enterotomy (80) inthe ileum (6), with links (730) protruding outwardly through theenterotomy (80). With plate (710) disposed in the duodenum (12) andplate (720) disposed in the ileum (6) as described above, plates (710,720) are released, allowing the bias of plates (710, 720) to draw theduodenum (12) and the ileum (6) closer together. At this stage, plate(710) bears on the tissue (7) of the duodenum (12) while plate (720)bears on the tissue (13) of the ileum (6) in the opposite direction,such that the layers of tissue (7, 13) are compressed between plates(710, 720) as shown in FIG. 29. This compression of tissue (7, 13)provides a secure seal of the anastomosis formed by the fully deployeddevice (700). Over a period of time, the ischemia caused by thiscompression of tissue (7, 13) also eventually results in necrosis of thetissue (7, 13), as described above. Device (700) thus eventually breaksfree from the anastomosis site and passes through the patient'sgastrointestinal tract as described above in the context of device(100).

It should be understood that after device (700) has left the site of theanastomosis (2) (e.g., after tissue (7, 13) within the footprint ofdevice (700) has necrosed), the structural integrity of the anastomosis(2) remains secure due to natural tissue adhesions. In particular, theexterior of the duodenum (12) and the ileum (6) may have substantialserosa-to-serosa adhesion at this point, due to the sustained contactbetween the duodenum (12) and the ileum (6). In addition, the mucosa atthe interior of the duodenum (12) and the ileum (6) may have remodeleditself to provide a smooth mucosal transition (90) between the duodenum(12) and the ileum (6) at the site of the anastomosis (2). While plate(710) is applied in the duodenum (12) and plate (720) is applied in theileum (6) in the above example, it should be understood that plate (710)may instead be applied in the ileum (6) while plate (720) is applied inthe duodenum (12). Furthermore, device (700) may be applied in otherregions of the gastrointestinal tract or in some other portion of thehuman anatomy. Various other suitable ways in which device (700) may beconfigured and used will be apparent to those of ordinary skill in theart in view of the teachings herein.

VI. Miscellaneous

It should be understood that any one or more of the teachings,expressions, embodiments, examples, etc. described herein may becombined with any one or more of the other teachings, expressions,embodiments, examples, etc. that are described herein. Theabove-described teachings, expressions, embodiments, examples, etc.should therefore not be viewed in isolation relative to each other.Various suitable ways in which the teachings herein may be combined willbe readily apparent to those of ordinary skill in the art in view of theteachings herein. Such modifications and variations are intended to beincluded within the scope of the claims.

It should be appreciated that any patent, publication, or otherdisclosure material, in whole or in part, that is said to beincorporated by reference herein is incorporated herein only to theextent that the incorporated material does not conflict with existingdefinitions, statements, or other disclosure material set forth in thisdisclosure. As such, and to the extent necessary, the disclosure asexplicitly set forth herein supersedes any conflicting materialincorporated herein by reference. Any material, or portion thereof, thatis said to be incorporated by reference herein, but which conflicts withexisting definitions, statements, or other disclosure material set forthherein will only be incorporated to the extent that no conflict arisesbetween that incorporated material and the existing disclosure material.

Versions of the devices described above may have application inconventional medical treatments and procedures conducted by a medicalprofessional, as well as application in robotic-assisted medicaltreatments and procedures. By way of example only, various teachingsherein may be readily incorporated into a robotic surgical system suchas the DAVINCI™ system by Intuitive Surgical, Inc., of Sunnyvale, Calif.

Versions described above may be designed to be disposed of after asingle use, or they can be designed to be used multiple times. Versionsmay, in either or both cases, be reconditioned for reuse after at leastone use. Reconditioning may include any combination of the steps ofdisassembly of the device, followed by cleaning or replacement ofparticular pieces, and subsequent reassembly. In particular, someversions of the device may be disassembled, and any number of theparticular pieces or parts of the device may be selectively replaced orremoved in any combination. Upon cleaning and/or replacement ofparticular parts, some versions of the device may be reassembled forsubsequent use either at a reconditioning facility, or by a userimmediately prior to a procedure. Those skilled in the art willappreciate that reconditioning of a device may utilize a variety oftechniques for disassembly, cleaning/replacement, and reassembly. Use ofsuch techniques, and the resulting reconditioned device, are all withinthe scope of the present application.

By way of example only, versions described herein may be sterilizedbefore and/or after a procedure. In one sterilization technique, thedevice is placed in a closed and sealed container, such as a plastic orTYVEK bag. The container and device may then be placed in a field ofradiation that can penetrate the container, such as gamma radiation,x-rays, or high-energy electrons. The radiation may kill bacteria on thedevice and in the container. The sterilized device may then be stored inthe sterile container for later use. A device may also be sterilizedusing any other technique known in the art, including but not limited tobeta or gamma radiation, ethylene oxide, or steam.

Having shown and described various embodiments of the present invention,further adaptations of the methods and systems described herein may beaccomplished by appropriate modifications by one of ordinary skill inthe art without departing from the scope of the present invention.Several of such potential modifications have been mentioned, and otherswill be apparent to those skilled in the art. For instance, theexamples, embodiments, geometrics, materials, dimensions, ratios, steps,and the like discussed above are illustrative and are not required.Accordingly, the scope of the present invention should be considered interms of the following claims and is understood not to be limited to thedetails of structure and operation shown and described in thespecification and drawings.

I/We claim:
 1. A method of modifying a metabolic pathway of a digestivesystem comprising an intestinal tract, wherein the intestinal tractcomprises a small intestine, a large intestine, a colon, an ileocecaljunction, and a ligament of Trietz, wherein the small intestinecomprises a duodenum, a jejunum, and an ileum, wherein the smallintestine further comprises a first initial length and a duodenalpapilla, the method comprising creating a pathway within the intestinaltract by establishing a connection between a proximal location withinthe small intestine and a distal location within the intestinal tract,wherein the connection places the region of the small intestineassociated with the proximal location and the region of the intestinaltract associated with the distal location in communication, wherein theproximal location within the small intestine is distal to the duodenalpapilla, and wherein the pathway defines a second length of theintestinal tract between about 10% and about 70% of the first initiallength.
 2. The method of claim 1, wherein the proximal location iswithin the duodenum and the distal location is within the jejunum. 3.The method of claim 1, wherein the proximal location is within theduodenum and the distal location is within the ileum.
 4. The method ofclaim 1, wherein the proximal location is within the jejunum and thedistal location is within the jejunum.
 5. The method of claim 1, whereinthe proximal location is within the jejunum and the distal location iswithin the ileum.
 6. The method of claim 1, wherein the proximallocation is within the jejunum and the distal location is within thecolon.
 7. The method of claim 6, wherein the proximal location is atleast about 200 centimeters from the ligament of Treitz.
 8. The methodof claim 1, wherein the proximal location is within the ileum and thedistal location is within the ileum.
 9. The method of claim 1, whereinthe proximal location is within the ileum and the distal location iswithin the colon.
 10. The method of claim 1, wherein the proximallocation is within the jejunum, wherein the proximal location is furtherbetween about 10 centimeters and about 200 centimeters distal to theligament of Treitz.
 11. The method of claim 10, wherein the proximallocation is about 100 centimeters distal to the ligament of Treitz. 12.The method of claim 10, wherein the method further comprises insertingone or more flexible endoscopes into a patient via an oral cavity and/orthe anus.
 13. The method of claim 1, wherein the distal location iswithin the ileum, wherein the distal location is further between about10 centimeters and about 300 centimeters proximal to the ileocecaljunction.
 14. The method of claim 13, wherein the distal location isabout 250 centimeters proximal to the ileocecal junction
 15. The methodof claim 1, wherein the distal location is within a select one of anascending portion of the colon, a transverse portion of the colon, and adescending portion of the colon.
 16. The method of claim 1, wherein thefirst initial length of the small intestine comprises an overall lengthof the small intestine, and wherein the second length is less than about60% of the first initial length of the small intestine.
 17. The methodof claim 1, wherein the proximal location is about 100 centimeters fromthe ligament of Treitz, and wherein the distal location is about 250centimeters proximal to the ileocecal junction.
 18. The method of claim1, wherein the connection comprises a side-to-side anastomosis.
 19. Themethod of claim 18, further comprising forming the anastomosis bycompression, wherein the act of forming the anastomosis furthercomprises: (a) introducing a first magnetically attractable device to afirst attachment region at the proximal location; (b) introducing asecond magnetically attractable device to a second attachment region atthe distal location; and (c) compressing a first lumen wall at the firstattachment region and a second lumen wall at the second attachmentregion between the first and second magnetically attractable devices,wherein the first and/or the second magnetically attractable devicecomprises a magnet, and wherein the first magnetically attractabledevice comprises a surface configured to be oriented adjacent to acorresponding surface on the second magnetically attractable device. 20.The method of claim 18, further comprising forming the anastomosis bymechanical fastening, wherein the act of forming the anastomosis furthercomprises: (a) creating a first enterotomy at the proximal location; (b)creating a second enterotomy at the distal location; and (c)mechanically fastening the first and second enterotomies.
 21. The methodof claim 1, wherein the connection is established in a procedureselected from the group comprising an open procedure, a laparoscopicprocedure, an endoscopic procedure, a procedure using one or moreendoscopes inserted through one or more natural orifices, andcombinations thereof.
 22. A method of creating a pathway within theintestinal tract, the method comprising: (a) forming a first opening ina first hollow organ; (b) forming a second opening in a second holloworgan; (c) inserting a first compression device in the first opening;(d) securing a first resilient feature of the first compression deviceto a first portion of tissue adjacent to the first opening, wherein thesecured first resilient feature is positioned on the exterior of thefirst hollow organ; (e) inserting a second compression device in thesecond opening; (f) securing a second resilient feature of the secondcompression device to a second portion of tissue adjacent to the secondopening, wherein the secured second resilient feature is positioned onthe exterior of the second hollow organ; (g) moving the first and secondhollow organs toward each other to align the first and secondcompression devices with each other; and (h) securing the positions ofthe first and second compression devices relative to each other, whereina layer of tissue of the first hollow organ and a layer of tissue of thesecond hollow organ are compressed in apposition between the securedfirst and second compression devices.
 23. The method of claim 22,wherein the first opening is formed within a small intestine of theintestinal tract at a location distal to a duodenal papilla, and thesecond opening is formed proximal to an ileocecal junction.
 24. Themethod of claim 22, wherein the first opening is formed within a smallintestine of the intestinal tract at a location distal to a duodenalpapilla, and the second opening is formed distal to an ileocecaljunction.
 25. The method of claim 22, wherein the first opening isformed within a jejunum at a location about 100 centimeters distal to aligament of Treitz, and the second opening is formed within the jejunumat a location about 250 centimeters proximal to an ileocecal junction.26. The method of claim 22, wherein the first opening is formed within ajejunum at a location about one-third of a length of the jejunum distalto a ligament of Treitz, and the second opening is formed within thejejunum at a location about 250 centimeters proximal to an ileocecaljunction.
 27. The method of claim 22, wherein the first opening isformed in a proximal portion of a jejunum, and the second opening isformed distal to the first opening at a distance between about 10% andabout 70% of a length of a small intestine of the intestinal tract.